Client Intake Form

Date

MM

DD

YYYY

Client Name *

First Name

Last Name

Client Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Can I Leave a Message? *

Yes

No

Are You Interested in: *

In-Person Sessions

Virtual Sessions

Both

No Preference

Are you planning to use insurance for our services? *

Yes

No

Not Sure

Policy Holder's Birthdate? *

MM

DD

YYYY

Policy Holder Address (If different from client)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I authorize my health insurance to provide payment of benefits to Strong Heart Therapy. *

Yes

No

I understand that I am responsible for payment if my insurance company denies payment. *

Yes

No